Documenting Contact Lens Follow Ups in the Detailed Visit Overview (iPad)

There are several ways that you can document a contact lens follow up in Encompass. Depending on your preference, you'll want to do one of the following:

  • Document the follow up using a previous diagnosis. This is the quickest method to document a contact lens follow up when the patient has come in for a visit.
  • Document the follow up using a new chief complaint. This is the most-detailed method for documenting a contact lens follow up when the patient has come in for a visit.
  • Document the follow up using a nonvisit order. If the patient has called in because they like their trials and want to order a supply, you can use this method to quickly finalize their trial Rx without creating a new visit.
What do you want to do?
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (iPad).
  2. Document the follow-up complaint:
  3. Locate the CC/HPI|ROS section header, tap the Add CC/HPI or ROS drop-down, and select Follow-up Complaint.

    1. Locate the diagnosis you're following up on and tap the +.

      A list of follow up questions appears on the right side of the screen.

    2. Tap the The patient presents for drop-down menu and select Further Evaluation and Management.
    3. Answer any other questions as needed and tap Save.

      The follow up chief complaint is created.

  4. Document the contact lens prescription:
    1. Open the Vision Exam screen. To learn how, go to Opening the Vision Exam in the Detailed Visit Overview (iPad).
    2. Tap the Wearing (WRx) tab.
    3. Tap Add Soft CL for soft contact lenses, or tap Add Specialty CL for RGP, scleral, or custom contact lenses.
    4. Tap View/Import Refraction Hx at the top of the screen.
    5. Tap the prescription the patient is currently wearing.
    6. Tap Import.
    7. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    8. Tap Save.

  5. If the lens was successful for the patient, tap + Final Rx on the trial lens.

    If the lens was unsuccessful, tap the Contact Lens tab and document the next trial lens the patient will be trying out.

  6. Tap Overview on the action bar to return to the Detailed Visit Overview.
  7. Tap Finalize Visit.
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (iPad).
  2. Document the follow-up complaint:
  3. Locate the CC/HPI|ROS section header, tap the Add CC/HPI or ROS drop-down, and select Chief Complaint.
    1. Select Contact Lens Detailed from the list of complaints.

      The chief complaint details screen opens.

    2. On the Is this a new presentation, or a follow-up? tab, select the Follow Up Contact Lens Evaluation option.
    3. Answer any additional questions as needed and tap Save.

      The follow-up chief complaint is created.

  4. Document the contact lens prescription:
    1. Open the Vision Exam screen. To learn how, go to Opening the Vision Exam in the Detailed Visit Overview (iPad).
    2. Tap the Wearing (WRx) tab.
    3. Tap Add Soft CL for soft contact lenses, or tap Add Specialty CL for RGP, scleral, or custom contact lenses.
    4. Tap View/Import Refraction Hx at the top of the screen.
    5. Tap the prescription the patient is currently wearing.
    6. Tap Import.
    7. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    8. Tap Save.

  5. If the lens was successful for the patient, tap + Final Rx on the trial lens.

    If the lens was unsuccessful, tap the Contact Lens tab and document the next trial lens the patient will be trying out.

  6. Tap Overview on the action bar to return to the Detailed Visit Overview.
  7. Tap Finalize Visit.
  1. Create a new nonvisit order. To learn how, go to Creating a Nonvisit Order (iPad).
  2. Add free-text note describing the nature of the order:
    1. Locate the Additional Visit Notes section and tap Add Visit Notes.
    2. In Note Body, type a reason for the nonvisit order. For example, "Patient called and wants to order trials. OK to order per doctor."
    3. Tap Save.
  3. Document the trial contact lens prescription:
    1. Tap More on the action bar and select G & C from the drop-down menu.
    2. Tap the Trials tab.
    3. Tap Add Soft Contacts for soft contact lenses, or tap Add Specialty Contacts for RGP, scleral, or custom contact lenses.
    4. Tap View/Import Refraction Hx at the top of the screen.
    5. Tap the prescription the patient is currently wearing.
    6. Tap Import.
    7. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    8. Tap Save.
  4. Tap Overview on the action bar to return to the order overview.
  5. Tap the Finalize Order button.
  6. Tap Finalize to confirm.